Purpose: This study highlights the clinical and radiological challenges in distinguishing ovarian malignancy from pelvic tuberculosis (TB), underscoring the need for precise diagnosis and appropriate treatment. Background: Pelvic TB, a rare extrapulmonary form of tuberculosis, presents diagnostic challenges, particularly in developed countries where it is less prevalent. Its symptoms, including chronic pelvic pain, menstrual irregularities, and adnexal masses, can mimic those of ovarian cancer, leading to potential misdiagnosis. Although TB is uncommon in developed nations, it remains a significant global health issue, particularly affecting individuals from endemic regions. Pelvic TB typically spreads to reproductive organs through lymphatic dissemination, direct extension, or hematogenous routes. Case Presentation: A 46-year-old woman presented with abdominal pain, abnormal vaginal bleeding, breathlessness, weight loss, and night sweats. She had a history of lung sarcoidosis, recurrent chest infections, and prior TB exposure. Initial imaging suggested advanced ovarian malignancy, but an omental biopsy revealed granulomas consistent with sarcoidosis. Further tests confirmed disseminated TB, and the patient underwent a 9-month course of anti-tuberculous therapy, which resolved most disseminated TB lesions. However, a persistent complex pelvic cyst required conservative follow-up. Conclusion: Although pelvic TB is rare in developed countries, it should be considered in the differential diagnosis of pelvic masses with ascites and elevated CA 125, especially in patients with recurrent chest infections and TB exposure.